Town and Country Animal Hospital 1001 Schippel Drive Salina, KS 67401 (785)823-2217 www.tcvets.com
Date _____________ Owner’s Name ____________________________ Pet’s Name __________________________
Please review the following information carefully to ensure you understand our recommendations.
Periodontal disease is the most common health problem of dogs and cats, affecting up to 85% of pets. Not only does dental disease affect the mouth, it can damage other vital organs, including the heart, kidneys, liver and lungs. By having a dental procedure performed on your pet you are taking a very important step toward preserving your pet’s health and comfort. When any dental procedure is being performed, it is important that the degree of periodontal disease is assessed. This is best done when the pet is under anesthesia. Once your pet’s mouth has been evaluated, the need for additional diagnostic and treatment options may arise.
I have reviewed the information about pre-anesthetic blood work that has been provided and would like you to perform the following recommended tests: Kittens <1 year of age (CBC & Pre-Surgical), Adults 1-6 years of age (CBC &
Pre-Surgical Profile), Mature Adults >6 years of age (CBC, Chemistry Profile & Thyroid Test)
CBC/Pre-Surgical ($59.69) □ Minimum Required
CBC/Chemistry Profile ($100.86) □ Recommended
Thyroid Test ($48.66) □ Recommended
□ I accept the recommended blood work. □ I decline the recommended blood work.
Teeth may need to be extracted if they are broken, loose, retained (baby teeth) or otherwise causing a problem.
Extraction prices vary depending on the tooth involved.
Extractions □ I accept □ I decline □ Call me for approval of extractions.
We now offer digital radiography to better assess the health of your pet’s teeth. Dental x-rays allow us to look beyond the obvious and better examine the teeth and supporting structures below the gum line. X-rays are warranted in the case of fractured teeth, significant periodontal disease, extractions and oral masses.
Dental X-Rays □ I accept □ I decline □ Call me for approval of dental x-rays.
Routine dentals do not usually require pain management; however, we may recommend pain medications if there are extractions, oral surgery or severe gingivitis.
Pain Medication □ I accept, please provide my pet with pain medication if deemed necessary.
□ I decline pain medication.
Intestinal parasites, such as roundworms and hookworms are infectious to people. Often times it is difficult for you to collect a fresh stool sample and bring it to our clinic. If your pet defecates while at the clinic, would you like us to test it for parasites?
Fecal ($18.55) □ I accept □ I decline
A microchip is the best form of identification because it is permanent, unlike a collar and tags which can get lost. A microchip can be implanted at any time.
Home Again Microchip ($41.00) □ I accept □ I decline □ My pet already has a microchip.
Feline immunodeficiency virus (FIV) and leukemia (FeLV) infections are major causes of illness and death in cats. Both viruses are contagious, spread easily from cat to cat. Early detection of infection will help you not only to maintain the health of your own cat, but also allow you to prevent spreading infection to other cats.
Our FIV/Felv tests also include a heartworm test because heartworm disease in cats is more common than once believed. FIV, FeLV & Heartworm Test ($38.78) □ I accept □ I decline □ My cat has been tested.
Dental Consent Form

Town and Country Animal Hospital 1001 Schippel Drive Salina, KS 67401 (785)823-2217 www.tcvets.com
Heartworm disease develops when a dog is bitten by a mosquito carrying microscopic heartworm larvae.
Adult heartworms often cause lung disease and heart failure. A heartworm test, which is ran using a small blood sample, is recommended yearly to ensure your pet is healthy and heartworm free. We also have a
Heartworm +Wellness blood profile that provides us with an abbreviated chemistry profile, as well as a heartworm test. Heartworm testing is for dogs that are over the age of 6 months.
Heartworm test ($26.25) □ I accept □ I decline □ My dog has been tested within the last year.
If needed, IV Catheter/Fluid Therapy will keep your pet hydrated during the procedure, and will compensate for any blood loss. Fluids also help maintain adequate blood pressure, and the catheter gives us venous access in case your pet should need any IV medications. Also it can be the difference between life and death in the case of a complication.
IV Catheter/Fluid Therapy ($67.00) □ I accept □ I decline
Misc Services Available:
Pedicure □ I accept (Complimentary) Ear Cleaning □ I accept ($12.00)
Vaccinations:
Please perform the following vaccines:
Feline Vaccines
Rabies $19.50 (REQUIRED VACCINE)
FVRCP-C $40.70
Leukemia $26.40
Canine Vaccines
Rabies $19.50 (REQUIRED VACCINE)
□ I accept
□ I accept
□ I accept
□ Current (Proof Required)
□ I decline
□ I decline
□ Current
□ Current
DHP/P-C $40.70
Bordetella $14.30
Influenza $20.00
□ I accept
□ I accept
□ I accept
□ I accept
□ Current (Proof Required)
□ I decline
□ I decline
□ I decline
□ Current
□ Current
□ Current
ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR RABIES VACCINE AND MUST BE FREE OF
EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT THE
OWNER’S EXPENSE.
I understand that with any anesthesia and/or surgical procedure there is a possibility of complications. Since the need for the above procedures is unpredictable, it is imperative that we be able to reach you during your pet’s dental. Please indicate which of the following options you prefer:
□ I prefer that you proceed with all necessary dental procedures. I understand that I will be responsible for all additional charges.
□ I prefer to be called before any additional procedures, other than emergencies. If I cannot be reached, I authorize you to proceed with all necessary dental procedures. I understand that I will be responsible for all additional charges.
□ If I cannot be reached by phone, I do not authorize any unforeseen dental procedures.
Signature _________________________________________________________ Date:
Phone number that you can be reached at: _______________________________________________
Dental Consent Form